Rheumatoid arthritis (RA) is a chronic systemic inflammatory autoimmune disease. Main characteristics include symmetrical synovitis and joint erosion; extra-articular manifestations affect the lungs, eyes, heart, and blood vessels. RA affects approximately 1% of the population, striking women in a 3:1 ratio to men. The usual age of onset lies between 30 and 60, but the disease can strike at any age. Symptom severity and disease progression vary widely between individuals. Onset may be rapid or insidious.

The etiology of RA remains elusive, but a genetic link involving the major histocompatibility complex class II antigens has been identified. Medical researchers suspect that environmental factors in conjunction with genetic predisposition may trigger RA.

• Genetic predisposition
• Environmental factors may include bacterial or viral infection and hormonal status
• Psychological stress (possible)
• Female gender
• Typically ages 30 to 60, although RA occurs at all ages

• Malaise, low-grade fever, weight loss, and stiffness in and about joints following inactivity
• Morning stiffness lasts for more than one hour
• Arthritis of more than three joints; specifically, proximal interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle, and metatarsophalangeal joints
• At least one affected hand joint; specifically, wrist, metacarpophalangeal, or proximal interphalangeal joint
• Extra-articular symptoms such as rheumatoid nodules, pleural effusion, pericarditis, lymphadenopathy, splenomegaly with leukopenia, vasculitis, normochromic, normocytic anemia, and elevated ESR.

• Ankylosing spondylitis and seronegative spondyloarthropathy
• Diffuse connective tissue disease, including systemic lupus erythematosus, scleroderma, dermatomytosis/polymyositis, vasculitis, and mixed connective tissue disease
• Other forms of arthritis, including infectious arthritis, reactive arthritis, and osteoarthritis
• Glucocorticoid withdrawal syndrome
• Gout, pseudogout
• Calcium pyrophosphate dihydrate deposition disease
• Chronic fatigue syndrome
• Fibromyalgia
• HIV infection
• Intermittent hydrarthrosis
• Lyme disease
• Malignancy, occult malignancy
• Parkinson's disease (with regard to swan neck deformities of the hands)
• Polymyalgia rheumatica and giant cell arteritis

The patient experiences joint stiffness, tenderness, and pain; the affected joints are swollen and may be warm to the touch. Approximately 20% of patients present with subcutaneous nodules located over bony prominences or within bursas or tendon sheaths. Some patients exhibit splenomegaly and lymph node enlargement; low-grade fever, anorexia, weight loss, fatigue, and weakness are more common. In advanced cases, symptoms include skin and muscle atrophy; dryness of the eyes, mouth, and other mucous membranes; and physical deformities.

Blood tests reveal several abnormalities:

• Rheumatoid factor (IgM antibody directed against IgG) present in 80% of cases
• Antinuclear antibodies present in 25% of cases
• Elevated erythrocyte sedimentation rate
• Elevated levels of gamma globulins (typically IgM and IgG)
• Platelet count may elevate due to inflammation
• Moderate hypochromic normocytic anemia
• Leukopenia (frequent with splenomegaly)

Arthrocentesis may reveal:

• Straw-colored joint fluid that is slightly cloudy and contains flecks of fibrin
• White blood cell counts at 5,000 to 25,000 per mm (>85% polymorphonuclear leukocytes)
• IgG may approach serum levels
• Depressed glucose level (may be less than 25 mg/dL)

• Synovitis
• Pannus formation (i.e., thickening of synovium)
• Cartilage breakdown
• Bone erosion

In later stages of the disease, X rays can reveal joint space narrowing and joint destruction.

• Patient's report of symptoms
• Physician assessment of physical symptoms
• Results of laboratory tests
• American College of Rheumatology criteria (five of the following seven, with numbers 1 through 4 continuous for at least six weeks): (1) Morning stiffness greater than one hour; (2) Arthritis in at least three joint groups with soft tissue swelling or fluid; (3) Swelling involving at least one of the following joint groups: ploximal interpalangeal, metacarpophalangeal, or wrists; (4) Symmetrical joint swelling; (5) Subcutaneous nodules; (6) Positive rhematoid factor test; (7) Radiographic changes consistent with RA

Treatment is typically aimed at relieving symptoms, preventing joint degradation, and preserving joint function. Traditional treatment involves a conservative approach using nonpharmacologic therapy and nonsteroidal anti-inflammatory drugs for up to a year before resorting to aggressive therapies. However, as substantial joint destruction can occur within two years of developing RA, the current recommendation is to treat RA earlier and more aggressively. Other general treatment strategies include the following.

• Whole-body rest to reduce systemic inflammatory response and combat RA-associated fatigue
• Articular rest such as joint relaxation techniques, assistive devices, and splints
• Heat and cold treatment
• Exercise to preserve joint motion, strength, endurance
• Surgery (e.g., carpal tunnel release, resection of metatarsal heads, total hip or total knee arthroplasty) to address joint destruction, deformation, or refractory pain

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, ketoprofen, naproxen, tolmetin, diclofenac, and diflunisal reduce pain and inflammation. Gastrointestinal side effects are common and may include ulcers and bleeding. The recently FDA-approved celecoxib selectively inhibits cyclooxgenase-2 and has a reduced risk of gastrointestinal side effects. Many more "COX-2" drugs are expected to be approved shortly.

Disease-modifying antirheumatoid drugs (DMARDs) include gold salts (injectable or oral), antimalarials (e.g., hydroxychloroquine), penicillamine, and sulfasalazine. DMARDs also include immunosuppressive drugs such as methotrexate, azathioprine, and cyclophosphamide. Beneficial effects may not be apparent for weeks or months. Most DMARDs have serious side effects including gastrointestinal symptoms, thrombocytopenia, myelosuppression, proteinuria, and hepatotoxicity.

Costicosteroids (glucocorticoids) have both anti-inflammatory and immunosuppressive effects. Drugs such as prednisone (5 to 15 mg predinsone or equivalent daily, for short-term use) and methylprednisolone relieve symptoms quickly and may be given orally or by injection. Side effects include osteoporosis, mood changes, fluid retention and weight gain, and hypertension.

Some patients do not respond to individual DMARDs and better results may be achieved through drug combination. For example, a combination of methotrexate, hydroxychloroquine, and sulfasalazine may be more effective than methotrexate alone.

Experimental therapy options include the following.

• Zileuton, a 5-lipoxygenase inhibitor, is under FDA review for treatment of mild synovitis
• Oral Type II collagen
• Minocycline
• Recombinant human interleukin-1 receptor antagonist
• Antibodies to TNF-alpha
• Anti-CD4 monoclonal antibodies
• Cyclosporine
• Mycophenolate mofetil

The goal of therapy is to decrease inflammation and preserve joint function. Because some, but not all, cases of RA respond to dietary changes, a trial should be informative and may be helpful. Proper nutrition is often a mainstay of complementary therapies. Herbs may be helpful for decreasing the severity and frequency of attacks. Treatment is long term.

• The most common allergic foods are wheat, corn, and dairy. Elimination/challenge diets may identify whether these foods constitute a problem. Avoid foods completely for two weeks, then reintroduce the foods one at a time, every three days, and note symptoms. Citrus, chocolate, alcohol, red meat, flour products, spices, and carbonated drinks may also aggravate RA.
• A vegetarian diet high in antioxidants may provide relief from the symptoms. This diet has high amounts of flavonoids (green tea [Camellia sinensis], blueberry , elderberry [Sambucus nigra]) and low amounts of saturated fats.
• A small percentage of people respond dramatically to a diet free of nightshades. They include peppers, eggplant, tomatoes, and white potatoes. A month-long trial is recommended.
• Selenium levels are low in people who have RA. One clinical study demonstrated that selenium combined with vitamin E reduces RA symptoms. Dose is 50 to 75 mcg/day of selenium and 400 to 800 IU of vitamin E.
• Zinc (45 mg/day) and manganese (45 mg/day) have both been found to be low in persons with RA.
• Omega-3 fatty acids suppress the production of inflammatory compounds produced by white blood cells. Dose is 1,000 to 1,500 IU/day.
• Bromelain is a proteolytic enzyme that when taken away from food is an anti-inflammatory (when taken with meals, it acts as a digestive enzyme). Dose is 2,000 to 2,500 mg bid.
• Quercetin stabilizes mast cells, found in increased numbers in the synovial membranes of affected joints. Dose is 250 to 500 mg tid away from food.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as teas, dried extracts (capsules, powders), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Devil's claw (Harpagophytum procumbens): analgesic, anti-inflammatory
• Ginseng (Panax ginseng): adaptogen (tonic for long-term stress), specific for chronic disease or condition and the effects of suppressive medications
• Ginger (Zingiber officinale): antispasmodic, digestive stimulant, anti-inflammatory
• Valerian (Valeriana officinalis): sedative, anodyne, antispasmodic, bitter. Helpful for pain control, especially if pain causes sleep disturbances.
• Blue flag (Iris versicolor): cholagogue (stimulates liver to process effects of inflammation)
• Wild yam (Dioscorea villosa): antispasmodic, bitter, specific for RA, adaptogen
• Horsetail (Equisetum arvense): diuretic, stabilizes connective tissue
• Devil's claw and three to five of the above herbs can be mixed as either tincture 30 to 60 drops tid, or 1 cup tea tid.

Other herbs to consider to reduce excessive immune response include gana derma, maitake mushroom (Grifola frondosa), and turmeric (Curcuma longa). Other anti-inflammatory herbs to consider include boswelia, sarsaparilla (Smilax species), gotu kola (Centella asiatica), and ashwaganda (winter cherry, Winthania somnifera).

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Rhus toxicodendron for arthritis that feels worse in the morning, in damp, cold weather and/or before a storm, and feels better with heat, dry weather, and upon moving the joints
• Bryonia alba for arthritis that feels better with pressure, feels worse with any movement, and/or cold weather, but also feels worse with getting overheated
• Ruta graveolens for arthritic pains that feel worse after exertion, feel better after resting, especially with a history of strains/sprains to the joints
• Calcarea carbonica for arthritis that is associated with weakness and cold clammy extremities that feel worse in the cold

May be helpful at decreasing pain, improving joint function, and delaying disease process.

May be helpful in relieving symptoms and increasing mobility.

• Side effects of pharmacologic treatment
• Osteoporosis prevention
• Periodic blood tests and X rays

• Joint infection
• Cardiopulmonary complications
• Systemic vasculitis
• Gastrointestinal complications
• Amyloidosis
• Joint erosion or destruction
• Skin vasculitis

RA varies widely among individuals. Approximately 15% to 20% of cases have an intermittent course with periods of partial to complete remission. Flare-ups may involve more joints than were initially affected, but remission periods often last longer than flare-ups. A further 10% of cases have periods of long clinical remission. The majority of cases (65% to 70%) are progressive; the rate of progression can be slow or rapid.

Early age of onset, high rheumatoid factor titer, and elevated erythrocyte sedimentation rate correspond to a poor prognosis. Involvement of more than 20 to 30 joints and presence of extra-articular symptoms also correspond with a poor outcome. Women generally have a poorer outcome than men. Individuals experiencing unrelieved symptoms for two or more years are at increased risk of premature death due to infection, heart disease, respiratory failure, renal failure, and gastrointestinal disease.

• Seventy-five percent of female RA patients experience symptom remission with pregnancy.
• Most DMARDs must be paired with effective contraception.

American College of Rheumatology, Clinical Guidelines Committee. Guidelines for rheumatoid arthritis management. Arthritis Rheum. 1996;39:713-722.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:121, 135, 150-151, 138, 226-227.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998:810.

Kelley WN, Harris ED, Sledge CB, eds. Textbook of Rheumatology. 5th ed. Philadelphia, Pa: WB Saunders Co; 1997: chap 55.

Mazzetti I, Grigolo B, Borzai RM, Meliconi R, Facchini A. Serum copper/zinc superoxide dismutase levels in patients with rheumatoid arthritis. J Clin Lab Res. 1996;26(4):245-249.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:73-75, 85-86, 226, 329-330.

Mulherrin DM, Thurnham DI, Situnayake RD. Glutathione reductase activity, riboflavin status, and disease activity in rheumatoid arthritis. Ann Rheum Dis. 1996;55:837-840.

Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998:492-501.

Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment, 1999. Stamford, Conn: Appleton & Lange; 1999.

Weisman MH, Weinblatt ME, eds. Treatment of the Rheumatic Diseases: Companion to the Textbook of Rheumatology. Philadelphia, Pa: WB Saunders Co; 1995: chap 3.

Wylie G, et al. A comparative study of Tenidap, a cytokine-modulating anti-rheumatic drug, and diclofenac in rheumatoid arthritis: a 24 week analysis of a 1-year clinical trial. Br J Rheumatol. 1995;34:554-563.

Zurier RB, Rossetti RG, Jacobson EW, et al. Gamma-linolenic acid treatment of rheumatoid arthritis: a randomized, placebo-controlled trial. Arthritis Rheum. 1996;39:1808-1817.